“After watching some E/M presentations, it was suggested that hospital consultations should be billed with CPT 99252-CPT 99255. When we billed these codes, our EMR system and our clearing house rejected the codes. They are saying effective 1/1/2010, CMS has announced that they will reject these codes. Are we billing the right codes?”
The information that was provided is correct. As of January 1, 2010, CMS/Medicare no longer accepts/recognizes E/M Consultation Codes (CPT 99252-CPT 99255). The correct inpatient consultation codes for a first evaluation are CPT 99221-CPT 99223. These codes are used for the inpatient E/M service, as well as any specialty consultation (limited to one visit from each specialty). In the past, the E/M codes CPT 99221-CPT 99223 were used only for the admitting physicians, and the codes CPT 99252-CPT 99255 were designated for consulting physicians. The consulting physician codes were dropped from Medicare guidelines due to discrepancies in paid consulting fees and the proper criteria required for those services. The new guidelines require consulting providers also to use CPT 99221-CPT 99223.
That being said, this is from a CMS/Medicare standpoint. Not all health insurance carriers follow CMS/Medicare’s rules/guidelines regarding Consultation/E/M Codes. Some health insurance carriers may still want the original inpatient consultation E/M codes to be billed. It is important to access/contact the specific health insurance carrier in order to find out the E/M codes that they require to be billed and documented for consultations that are provided.
As of January 1, 2023, the definitions of the E/M services in question are the following:
Initial Hospital Inpatient or Observation Care New or Established Patient:
• CPT 99221 Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level medical decision making.
• When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.
• CPT 99222 Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.
• When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded.
• CPT 99223 Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making.
• When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.
• (For services of 90 minutes or longer, use prolonged services code CPT 993X0)
Inpatient or Observation Consultations New or Established Patient:
• CPT 99252 Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
• When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.
• CPT 99253 Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making.
• When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.
• CPT 99254 Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.
• When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.
• CPT 99255 Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and high level of medical decision making.
• When using total time on the date of the encounter for code selection, 80 minutes must be met or exceeded
• (For services 95 minutes or longer, use prolonged services code CPT 993X0)
This is my opinion.
Michael G. Warshaw
DPM, CPC
GREAT NEWS!!!
THE 2024 PODIATRY CODING MANUAL IS NOW AVAILABLE in either Book or Flashdrive formats. It has been completely updated for the calendar year 2024. Many offices across the country consider this to be their “Bible” when it comes to coding, billing, and documentation. The price is still only $125 including shipping! To purchase, access the website drmikethecoder.com.
No credit card? No problem! Just send a check for 125.00 to the following address:
Dr. Michael G. Warshaw
2027 Bayside Avenue
Mount Dora, Florida 32757
Read Comments